Shortage of child psychiatrists has families scrambling for help

A national shortage of psychiatrists who treat children, and difficulty in getting in to see those who do, means that many young people who need psychiatric medication are denied that service.

Only 20 percent of children with psychiatric problems receive treatment, according to one veteran child psychiatrist, and the problem is much worse in the interior of the country.

Whether this will affect the young people of Newtown who survived the horrific Dec. 14 shootings cannot be known for certain, but the need for mental health services has been demonstrated by the many professionals who have gone to the town to help in the wake of the killings of 20 children and six staff members at Sandy Hook Elementary School.

The problem is highlighted by the Newtown tragedy, but it affects every town and city, according to numerous professionals consulted.

"It's really, really hard for someone to get an appointment quickly," said Suzanne Serviss, a social worker at Branford High School. One case took two months before the child got an appointment, she said.

"That is a nearly universal problem all over the country," especially away from the coasts and cities, said Gregory Fritz, director of child and adolescent psychiatry at the Brown University School of Medicine and academic director for Bradley Hospital in Providence, R.I. "It's been a problem for a long time.

"What is behind it is basically that there are too few child psychiatrists," with at least twice as many needed as the 8,000 certified in the United States. He said only a fifth of children who need such help receive it.

FEW TAKE INSURANCE

Few child psychiatrists will take health insurance, so the out-of-pocket costs can be burdensome. Parents have to pay the doctor's full fee of as much as $200 and then submit the bill to their insurer, assuming the doctor is on the insurer's roster of providers or the family's insurance plan covers out-of-network providers. Even then, there may be a high deductible.

"Essentially there's no competition," Fritz said. "In most places, they can see people and just say, 'I'm not going to fool around with insurance.'"

There are essentially three reasons for the shortage, according to Fritz:

?It takes a minimum of five years in medical school to become certified in both adult and child psychiatry and can be longer, similar to some higher-paying specialties. More years in school mean higher student loans.

"The medical students to my eye now pay a little more attention to income ... and the reason is their debt is much higher," Fritz said. He said child psychiatrists earn about the same as general practitioners. So, many students who want to work with children go into pediatrics instead.

?Insurance reimbursements are given for the service, not the time spent on evaluations or medication sessions. "The problem is it takes longer to do it for a child," because parents and teachers must be consulted. "Fundamentally, the payment per hour is less," Fritz said.

?Finally, "there is still significant stigma about mental illness and psychiatric patients, and that stigma also applies to those who treat those stigmatized patients," Fritz said.

In addition to many child psychiatrists not being willing to take insurance reimbursements, there are other symptoms of the malady:

?The wait to see a doctor can be weeks long.

?Since child psychiatrists are certified to see adults as well, those who take insurance may fill part of their schedule with older patients, bringing quicker reimbursements and limiting the slots for children.

The Register called several doctors' offices listed on Aetna's website as "Psychiatry, child and adolescent." Of those who responded, all said they treat adolescents only, despite being listed as treating children as well.

"I will see about age 15 and my partner will see a little bit younger; he'll see 14," said Dr. Douglas Berv of Hamden. "I'm not trained or certified with children and that's where you're running into a problem."

He said of the rosters of providers issued by insurance companies, "Their lists are never correct."

Another on Aetna's "child and adolescent" list, Dr. Robert Ostroff, head of adult psychiatry at the Yale Psychiatric Hospital, said he does not treat children and has heard of the problems in finding doctors who do.

"It's been very hard to get my insured patients' children seen by child psychiatrists," he said. "I have people who can't afford to pay out of pocket. ... It's a real problem."

When asked about the combined "child and adolescent" category, Susan Millerick, a spokeswoman for Aetna, after reviewing the issue, said Aetna would look into whether the categories could be divided on the company's DocFind service.

"Given the difficulties that exist in finding a child psychiatrist or behavioral health practitioner for small children, we want to make it easier for people to find those practitioners," she said. "We should make it as easy as we can."

HELPING IN NEWTOWN

This isn't to say child psychiatrists are not caring about those who need help. "So far there have been 50" adult and child psychiatrists "who have gone down to Newtown and the total hours have been over 300," said Jacquelyn Coleman, executive director of the Connecticut Psychiatric Society in Bloomfield.

Dr. Shaukrat Khan, chairman of CPS's Disaster Psychiatry Committee, said many more have volunteered to help. Coincidentally, a disaster training course had just been held Nov. 10, he said. "We are not prescribing any medications there," Khan said. "We are just bringing post-trauma counseling, grief therapy."

There are limited alternatives to private practice psychiatrists. For a town that has a children and family services agency, child psychiatrists may be easier to see.

The Branford Counseling Center has six part-time child psychiatrists available, three of them through an arrangement with the Yale Child Study Center, according to Patricia Andriole, head of the town department.

"Each year, we have three fellows who have finished their general psychiatric training and they are in their second year of a fellowship for child psychiatry," Andriole said.

That has a downside for psychotherapists who refer their clients to the Branford Counseling Center, because the center requires that patients seeing its psychiatrists must also see its therapists.

"We think that you need to have your treatment all in one place," said Andriole. "The psychiatrist is not the primary therapist."

"I'm a private practice clinician and I see children and families," said Linda Young, a licensed clinical social worker from Madison. "In order for some people who need a child psychiatrist to access their municipal services, they're required to see someone" in the youth and family bureau in their town. So Young loses the client.

The situation comes up because "usually there are no child psychiatrists on insurance panels," so the family can't use their work-related health benefits, Young said. "They're all private and I heard recently of someone charging $300 an hour." To use an out-of-network psychiatrist, Young said, a family would have to use up its deductible, which could be as high as $15,000.

Katrina Clark, executive director of the Fair Haven Community Health Center said the lack of child psychiatrists "is definitely an issue for our pediatric patients. We are working with Clifford Beers Clinic to provide several hours a week of a social worker on site for our pediatric patients, which will be a small improvement." She mentioned a situation in which a pediatrician was "told to wait months if not years for an appointment to diagnose a child with a condition such as autism."

NURSE AS ALTERNATIVE

There is an alternative route some therapists have taken: referring their patients to advanced practice registered nurses who have additional training in psychiatric medicine.

"APRNs are easier and that's who I refer to by and large," said Serviss. "I find them accessible and good and they communicate with me."

Ellen Prasinos, who has her own practice in Guilford as an adult and family psychiatric nurse practitioner, said APRNs "are a good alternative if they have good training on kids." (She said the state classifies nurse practitioners as APRNs. Those trained in psychiatry must collaborate with a psychiatrist.)

But, Prasinos said, "there are very few of us" who are certified to prescribe medications to children.

She said she doesn't take insurance because of the time she spends with her clients, both in the office (she sees each client for a minimum half-hour, even if it's to review medication) and off-hours.

"I text 24/7 with the kids that I take care of and their parents. When you see a kid you're really dealing with a whole family," she said.

Another possible ray of hope is the 25-year-old pilot programs run by nine medical programs that turn out doctors trained in both adult and child psychiatry in five years, said Brown's Fritz.

"It hasn't really grown much because it requires a lot of collaboration between the departments," he said.

Meanwhile, Bradley Hospital has to subsidize the child psychiatrists on its staff.

"If we paid only what their clinical work brought in, we couldn't attract child psychiatrists to do outpatient work," he said.